Some Groups Have Called for Unified Formulary
By Sandra Basu
WASHINGTON — Last year, a new policy instructed VHA providers not to discontinue mental health medications initiated by DoD providers due to formulary differences.
Now, a Government Accountability Office (GAO) report says that VHA needs to clarify which types of medications are covered by that 2015 policy. instructing.
“Because VHA’s policy lacks clarity, VHA providers may be inappropriately discontinuing mental health medications due to formulary differences, which could increase the risk of adverse health effects for transitioning servicemembers,” the report states.
GAO further explains that VHA providers it interviewed “had varying interpretations of which medications are covered by this policy, and VHA officials acknowledged that the definition of a mental health medication could be subjective.”
The findings were contained in a GAO review conducted from May 2015 to December 2015 to assess medication continuation for troops with PTSD or TBI transitioning from DoD to VHA.
The issue of medication continuation for transitioning troops has been a concern among lawmakers, and advocacy groups worried that, because of differing formularies at VHA and DoD, patients are having effective medications discontinued.
Last year, the Military Compensation and Retirement Modernization Commission (MCRMC) assessment concluded that DoD and VA needed to create a uniform formulary to include all the drugs identified as critical “for transition beginning immediately with the pain and psychiatric classes of drugs.”
A bill signed into law last November mandates that, as of June this year, both DoD and VA department pharmacies must stock the same medications to treat pain, sleep and psychiatric disorders.
VHA’s 2015 policy instructing its providers not to discontinue mental health medications initiated by DoD providers due to formulary differences is one of two efforts VHA has to ensure medication continuation for veterans, GAO explains. The other effort is through VHA’s nonformulary request process.
“VHA monitors nonformulary requests,” according to the report. “VHA data show that 81% of requests submitted from fiscal years 2012 through 2014 were approved, and 98% of requests were adjudicated within VHA’s required time frame of 96 hours.”
GAO reviewers also detail that, as of August of 2015, VA’s formulary included 57% of the psychiatric, pain and sleep medications on DoD’s formulary.
In fact, it determines that the “vast majority” of medications that were actually prescribed by DoD healthcare providers in FY 2014 were on both formularies.
“Additionally, we found the most agreement between the formularies for psychiatric medications, with the medications on VA’s formulary representing 98% of the prescriptions that had been filled by DoD in fiscal year 2014,” GAO states.
In the report, GAO recounts information provided by DoD and VHA, saying that formulary differences do not affect the extent to which VHA providers continued medications prescribed by DoD providers when clinically appropriate.
“Providers, pharmacists, and case managers we interviewed at three VAMCs and two Army MTFs, as well as military and veterans’ stakeholder groups, were generally unaware of specific instances of medications being changed or discontinued for nonclinical reasons, including formulary differences,” the GAO review finds.
Report authors write that, according to interviews with VHA providers and pharmacists, changes in medications most often are for clinical “such as side effects, the medication not working, interactions with other medications and general disagreement with the prior treatment approach.”
“Additionally, several VHA providers we interviewed said most of the psychiatric, pain and sleep medications they would want to prescribe are already on the VA formulary, and we found that the majority of the medications providers said were not on the formulary have recently been added,” the report notes.
The GAO document points out that, given the remaining differences in the formularies, some stakeholders have suggested DoD and VA utilize a single formulary.
VHA officials, however, were not in favor of adopting DoD’s formulary. “VHA officials expressed concern that adopting DoD’s formulary could diminish elements of their formulary process that they believe are important from a clinical and cost perspective,” according to the report..
It also states that, although VHA officials said they would be supportive of the idea of collaboratively creating a single formulary with DoD, DoD viewed it as “a reduction of the benefit that they currently provide.”
“In addition, DoD officials told us that current law requires them to include all clinically appropriate Food and Drug Administration-approved medications,” GAO writes.
Clarifying the Policy
In comments attached to the report, VA concurs with GAO’s recommendation and said it would clarify the medication policy with an estimated completion date of March 2016.
Additionally, the GAO recommends DoD direct the Army to implement processes to review and monitor Army MTF prescribing practices for medications discouraged under the PTSD guideline.
The report explains that DoD “relies on each military service to review the medication prescribing practices of its providers and that the Army does not monitor the prescribing of medications to treat PTSD on an ongoing basis.”
On the other hand, it says that “VHA monitors the prescribing of benzodiazepines and antipsychotics to treat PTSD nationally and by VAMCs and requires VAMCs to implement improvement plans if their prescribing is significantly higher than the average of all VAMCs.”
While DoD indicates agreement with the recommendation in attached comments, it points out that the VA policy approach “may not be optimal for the Army population needs.”
It states that providers will continue to be educated and trained on the recommendations in the clinical practice guidelines and also will “continue to leverage the Defense Health Agencies, such as the Pharmacovigilance Center to monitor overall trends in prescribing, as well as for monitoring selecting populations of special clinical interest, as appropriate.”
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.